Paul Tedrick
American Hospital Association – Chicago
July National Content Call
July 9, 2013
11:00AM CT
Operator: The following is the July National Content Call for Paul Tedrick, with the American Hospital Association of Chicago on Tuesday, July 9, 2013 at 11:00 a.m. Central Time. Excuse me, everyone. We now have our speakers in conference. Please be aware that each of your lines is in a listen only mode. At the conclusion of the presentation, we open the floor for questions. At that time, instructions will be given as to the procedure to follow if you would like to ask a question. I would now like to turn the conference over to Mr. Paul Tedrick. Sir, please begin.
Paul Tedrick: Good morning/afternoon, everyone, depending on where you’re at. I wanted to welcome you to the On the CUSP: Stop CAUTI Content Call series. Today’s topic is health literacy and patient and family engagement, strategic tools to prevent CAUTI. Our two speakers today are Barbara Meyer Lucas. She’s a Project Consultant with the Michigan Health and Hospital Association, Keystone Center for Patient and Safety Quality. Also is Milisa Manojlovich. She is an Associate Professor with the Division of Nursing Business and Health Systems at the University of Michigan School of Nursing. So without further ado, I’m going to turn the call over to Barbara Lucas.
Barbara Meyer Lucas: Thank you, Paul. Good afternoon, everybody. We’re going to be talking about two principal concepts during our time with you this afternoon, first helping you to understand the concept of health literacy and its role in your work on CAUTI prevention, and secondly, Milisa will be speaking with you about understanding the importance of engaging your patients and families to help your teams prevent CAUTI.
So moving to Slide 5, we’re starting, first of all, with an introduction to the concept of health literacy, and during this first half of the talk, we are hoping to leave you with a clear definition of the concept of health literacy and its implications for patient care. We’ll be walking through some of the major barriers that all of us face when we’re dealing with health literacy issues. And finally, we will be leaving you with some concrete strategies to help you enhance health literacy with the patients on your floor.
So moving now to the next slide, Slide 6, I wanted to start, first of all, by talking about what do we mean by health literacy? It’s a term that’s very much in vogue, and we hear a lot about on a number of process improvement and quality improvement projects we’re all involved in, but put very simply, health literacy is the ability to obtain, understand and act on health information. And it is very definitely dependent on a clear exchange between patients and their families and all of us on the medical team.
Moving to Slide 7, if we take a step back and think about what are the premier reports that got all of us initiated in the path to improving safety for our patients, the document called, “Crossing the Quality Chasm,”, which was released in 2001, from the Institute of Medicine; one of the major contributions that report made to all of our work, is by outlining key health care dimensions that we should all strive for in our patient care delivery settings, and that is that to have truly quality care, we need to make sure that that care is patient centered, timely, safe, effective, that is evidence based, efficient and equitable for all of the patient populations that we serve. So if we’re going to try to reach the establishment of these dimensions in the care we deliver, it’s really important that we lay the groundwork by improving our communications skills with our patients and the families that support them.
So moving to Slide 8, why would it be important for us to think about this communication aspect with our families? First of all, we know from the literature that patients with low health literacy are more likely to be hospitalized, so they’re at greater risk for winding up in the hospital. This is a study from the Journal of General Internal Medicine from 1999 that found that patients with low literacy are twice as likely to be hospitalized as patients that are literate.
If you move to Slide 9, we know that low health literacy also affects chronic disease management. One of the major areas that illustrated this was looking at diabetic patients, and this is a study from the Archives of Internal Medicine in 1998, that looked at some of the key components in terms of educating our diabetic patients. So when they checked to see whether or not diabetic patients could teach back to them the symptoms they should watch out for that might indicate their blood sugar was low, only 50 percent of patients with low literacy were able to describe those symptoms, as compared to 94 percent of patients who were literate. And perhaps more importantly, when we asked those patients, were they able to describe what they should do if they felt that their blood sugar was dropping, only 38 percent of patients with low health literacy were able to describe what steps they should take, compared to 73 percent of patients that had a greater degree of literacy. If we look also at the area of patient safety; all of you on your units are aware of the issue of sentinel events, and as you know, the Joint Commission collects data on those, and shares that feedback with us. So from a report that they released just this past February, we know that, for example, in 2010, there were 802 sentinel events reported to the Joint Commission, and 82 percent of those events listed communication issues as one of the key root causes contributing to those events. Similarly, they were involved in 61 percent of events in 2011 and 59 percent of events in 2012. So communication issues are often cited as one of the root causes that lead to significant safety issues, as characterized here by sentinel events in the last three years.
Moving on now to Slide 11, how does this apply to our CAUTI prevention efforts? One of the key focuses of our talk today will be helping you to get your patients and families more involved in preventing CAUTIs in their care, and so definitely, if they understand the rationale behind that, we can help them contribute to making sure that we’re using the appropriate reasons for catheters, making sure that catheters are appropriately inserted and maintained, and patients can also be engaged in helping us be aware to the fact that they need to come out as soon as possible.
On Slide 12, again, when we improve our medical communication, it will enhance patient-centered and compassionate care for patients that do have catheters, help improve their patient safety by reducing infection risks, and hopefully reducing prolonged hospital stays due to CAUTIs.
So moving now to Slide 13, if health literacy is so important, what are the barriers that are preventing us from addressing this adequately? And I’ll be reviewing with you four major categories of barriers that we do find in regard to health literacy. First is the complexity of our current health care system. Secondly – patient factors. Third – physician attitudes and communication skills, and finally, nursing issues. There are other barriers as well, but these are the four major topics that we’ll be covering in the next few minutes. So starting, first of all, with the complexity of our health care systems, if you think back to the way health care was delivered 35 years ago, as compared to today, you can look, for example, at the treatment of Acute Myocardial Infarction or heart attacks. So 35 years ago, if a patient was seen and admitted to the hospital for an AMI, they generally stayed in the hospital for four to six weeks of bed rest. And now, we usually have a length of stay of two to four days. Thirty-five years ago in the PDR, there were roughly 800 prescription drugs available, and now there are more than 10,000. Also, the treatment of newly diagnosed diabetes 35 years ago was very different from what we do today, in that a newly diagnosed diabetic was typically admitted to the hospital and received two hours per day of diabetic education before they were released as being judged to be relatively competent to manage their problem at home. Now, largely, this is done with outpatient management, perhaps zero to three hours of classes. We rely on handouts, internet, and in some cases, telemedicine to manage our diabetic patients. So a very different scenario from 35 years ago.
Moving now to Slide 15, as I said, there is an increasingly complex health care system, and this is also manifested by the fact that many patients now, if they are admitted, are not cared for by their primary care physician or their family physician, but by the use of hospitalists, or they may be in a teaching hospital with an academic service following them, so there is a disconnect from their regular provider. We now expect much more self care and self education. There are multiple handoffs, not only within our hospitals between units, but also to extended care facilities and ambulatory facilities. And as we know from our work with CUSP on the CAUTI project, every patient care unit has a different culture, a different set of expectations about how staff work together, and that can clearly impact how medical information is communicated to patients, and how well they understand. This is an example from one of these states that we work with in terms of safety culture, using HSOPS dimensions of safety culture. I think many of you on the CAUTI project have seen this type of slide when we’ve discussed your data with you. But this is an example of the disparity we often see, and this is a very typical pattern that we see when you look at system barriers in terms of teamwork within units versus teamwork across units and handoffs and transitions. So pretty much across the board, we’re finding that states were relatively high on how well they believed they’re working as a team within their units, but those handoffs across units, and those handoffs and transitions for teams, as well as patients, are perceived as being less safe. And all of this can definitely impact how we’re communicating information to our patients.
So moving to Slide 17, this is an example of some of the patient factors that can be barriers to understanding medical information. And this is the most recent national adult literacy survey that was reported out in JAMA in February of 2012, in which adult patients were scored on four levels to see how well they read just ordinary information. This was not health information per se, but ordinary reading material. And the study was really informative in that it found that only 12 percent of adults in this country read at a proficient level. That’s roughly at a high school graduate level. Fifty-three percent read at about an eighth grade level, but look at these triangles or the pie wedges that red and orange. It found that 21 percent of adults in the United States read at about a fourth grade level, or basic level, and 14 percent barely read at all. So if you combine those two wedges of the basic and below basic categories, roughly 35 percent of the patients that we are seeing in our health care settings essentially cannot read. They read at a fourth grade level or below, so roughly one in three of any patient that you’re trying to teach about their health care problem, or convey what you expect them to do when they leave the hospital or leave your ambulatory site, essentially are not good readers at all.
If you couple this then with the next slide, a patient-related barrier is aging. As our population ages, as the baby boomer population ages, their ability to read well also declines substantially. So in this study from JAMA in 1999, if you look at adult patients between ages 65 and 69, about 25 percent have marginal or inadequate literacy, but that goes all the way up to more than 70 percent by the time they’re over 85. So you couple the general difficulty reading in our population with aging, and we have a significant barrier to understanding health information.
Moving on to Slide 19, however, we just wanted to emphasize here that patients, when they present to you in the clinic or in the hospital, are extremely vulnerable because we have them sitting on exam tables naked, sitting on that crinkly paper, and it’s not really a teachable moment. Most people present to us for health care when they’re sick, when they’re afraid, when they’re embarrassed. They’re in a compromised setting already, and it’s not really a teachable moment for the best absorption of health information. So even for patients that generally do read well and generally can function in an ordinary situation, when they’re sick, when they’re tired, when they’re afraid, when they’re in pan, it’s an entirely different situation, and we have to keep that in mind when we’re trying to convey information about their health, particularly when we’re asking them to take action based on that information.
So moving to Slide 20, I want to touch briefly on some of the physician and nursing barriers that may occur when we’re trying to convey medical information. This cartoon saying, “I’m going to give you a mild sedative to counteract your really annoying questions”, and is meant just to exemplify some of perceived attitudes that physicians may have when they’re meeting with patients. Physicians frequently cite to me, when I do teaching about health literacy and communications skills, “I just don’t have time. I need to get in and out of the room. I have other rounds to do. I have to be down in another department. I have to go look at X-rays. I have another PAP schedule ahead of me for this afternoon in my clinic.” And so time is often cited. But we’re finding out more and more, as we study physician communication, that some physicians really have difficulty being questioned by patients, and struggle with being receptive to questions. So that can be an attitudinal issue that we have to come to grips with. Until recently, there has not been a major emphasis on communication skills in residency programs, but fortunately, that’s now changing. And this is one area that we do address with physicians, to each them how to be open to questions, and how to listen more, rather than just conveying information. So it’s an area that’s a subject of a much lengthier discussion than we have now, but something to keep in the back of your mind.